medications

Medication Study Guide

Acetaminophen

• Class: Antipyretic, Non-opioid Analgesic
• Indications:
  • Mild to moderate pain
  • Fever for patients > 3 months of age with temperature > 100.4°F
• Mechanism of Action:
  • Inhibits prostaglandin E2.
  • Elevates the pain threshold and adjusts hypothalamic regulatory center.
• Dose:
  • Pediatric: 15mg/kg PO/IV, Max 650mg. Administer slowly over 15 minutes.
  • Adult: 15mg/kg PO/IV, Max 1000mg.
  • 650mg PO / 1000mg IV; Max 650mg when weight < 65 kg.
• Side Effects:
  • Nausea, vomiting, constipation, Steven Johnson Syndrome.
• Contraindications:
  • Known hypersensitivity.
  • Last dose given < 4 hours prior.
  • Liver disease/failure.
• Associated Protocols:
  • 1000, 6003, 7003, 7007

Activated Charcoal

• Other Names: Inst Char; Acitidose-Aqua; Liqua-Char
• Class: Absorbent, Antidote
• Indications:
  • Most oral poisonings and medication overdoses in alert patients; can be used after evacuation of poisons.
• Mechanism of Action:
  • Absorbs ingested toxic substances from the GI tract, preventing systematic absorption.
• Dose:
  • Adults and Pediatrics (older than 1 year): 25-50 grams orally or via NG tube.
  • Pediatrics (younger than 1): 1g/kg orally or via NG tube (12.5-25 grams).
• Side Effects:
  • Nausea, vomiting, intestinal obstruction (with multiple doses).
• Contraindications:
  • Known hypersensitivity.
  • Altered mental status without protected airway.
  • Do not administer if the substance is not known to be absorbed by activated charcoal.
  • Corrosive ingestion as it can obscure endoscopy.
  • Seizures.
• Associated Protocols:
  • 8031. Activated charcoal may only be given by order of medical command or poison control.

Adenosine

• Class: Antiarrhythmic
• Indications:
  • Narrow complex REGULAR supraventricular tachycardia refractory to vagal maneuvers.
• Mechanism of Action:
  • Slows conduction through AV node; interrupts re-entrant pathways; chemically cardioverts.
  • It is naturally occurring in all cells, a byproduct of ATP breakdown.
  • Adenosine receptors located in lungs and cardiomyocytes stimulate decreased electrical conduction, decreased SA node automaticity, and slower conduction velocity.
• Dose:
  • Adult:
  • Attempt vagal maneuvers first.
  • 6mg (2cc) IV rapidly over 1-3 seconds, flush with 20cc NS bolus.
  • May repeat 12mg bolus once more in 2 minutes.
  • 3rd dose of 12mg requires medical command prior to administration.
  • Pediatric:
  • First dose: 0.1mg/kg (Max 6mg).
  • After 2 minutes, 0.2mg/kg (max 12mg).
• Side Effects:
  • Asystole, transient dysrhythmias, bronchospasm, chest pressure, flushing, hypotension, headache, nausea.
• Contraindications:
  • Sick sinus syndrome, 2nd or 3rd degree heart block, hypersensitivity, poison/drug-induced tachycardia, asthma or bronchospasm, ventricular tachycardia.
• Associated Protocols:
  • 5022A & P, 5023A & P

Albuterol

• Class: Bronchodilator / Anti-asthmatic
• Indications:
  • Bronchospasm due to COPD; Bronchial Asthma.
• Mechanism of Action:
  • Selective B2 agonist known for minimal side effects; relaxation of bronchial smooth muscles resulting in prompt bronchodilation.
• Dose:
  • Adults (>20 kg): 2.5mg-5mg nebulized @ 6-8 LPM (If mixed with Ipratropium Bromide: 3mg).
  • Pediatrics (< 1 year or
• Side Effects:
  • Tachydysrhythmias, anxiety, nausea/vomiting.
• Contraindications:
  • Angioedema, sensitivity to albuterol or levalbuterol.
  • Use with caution in lactating patients, cardiovascular disorders, and cardiac arrhythmias.
• Associated Protocols:
  • BLS 421, 3000A/P, 4011, 4022, 4023P, 6004

Amiodarone

• Class: Antiarrhythmic
• Indications:
  • Cardiac arrest (V-fib/V-tach); stable wide complex tachycardias.
• Mechanism of Action:
  • Prolongs myocardial cell action potential duration (phase 3) and refractory period.
  • Acts as a noncompetitive alpha and beta adrenergic inhibitor; delays repolarization and increases action potential duration.
• Dose:
  • VF/VT (pulseless): 300mg IV/IO; may repeat 150mg IV/IO in 10 minutes.
  • Stable Irregular Narrow Complex Tachycardia or Stable VT/Wide complex with a pulse: 150mg in 50-100ml NS over 10 minutes.
  • Recurrent VT or Runs of VT post-ROSC: 1mg/min infusion (Max 2.2g in 24hrs).
  • Pediatric:
  • VT (Pulsed) and SVT: 5mg/kg in 50ml NS over 20-60 minutes.
  • VF/VT (Pulseless): 5mg/kg IV/IO (Max 300mg).
• Side Effects:
  • Vasodilation, low BP, low HR, AV block, hepatotoxicity, Torsades, CHF.
• Contraindications:
  • Known hypersensitivity, iodine hypersensitivity, bradycardia, AV block > 1 degree without a pacemaker, hypotension (SBP < 100 mmHg).
• Associated Protocols:
  • 3031A/P, 3080, 5022P, 5023A & P

Ancef (Cefazolin)

• Class: Cephalosporin antibiotic
• Indications:
  • Open fractures, amputations.
• Mechanism of Action:
  • Inhibits bacterial cell wall synthesis leading to cell death.
• Dose:
  • Adult (>50kg): 2g IV/IO.
  • Peds (9 to ≤14 years old, 30-50kg): 1g IV/IO.
• Side Effects:
  • Nausea, vomiting, diarrhea, headaches.
• Contraindications:
  • Hypersensitivity, allergic to cephalosporins or penicillin.
• Associated Protocols:
  • 6093

Aspirin

• Class: Antiplatelet/NSAID
• Indications:
  • Chest pain, acute myocardial infarctions, mild to moderate pain in adults.
• Mechanism of Action:
  • Blocks formation of thromboxane A2, limiting platelet aggregation and arterial constriction.
  • Decreases levels of PGE2, reducing pain and inflammation.
• Dose:
  • 324mg (4 pills) PO (chewed).
  • 650mg PO (>14 years old).
• Side Effects:
  • GI bleeding.
• Contraindications:
  • Gastrointestinal bleeding, active ulcer disease, hemorrhagic stroke, bleeding disorders, children with chickenpox or flu-like symptoms, known hypersensitivity.
• Associated Protocols:
  • 5001, 6003, 7003

Atropine Sulfate

• Class: Antiarrhythmic; Antimuscarinic; Parasympatholytic; Antivagolytic
• Indications:
  • Hemodynamically significant bradycardia; organophosphate poisoning.
• Mechanism of Action:
  • Competes reversibly with acetylcholine at muscarinic receptors, blocking parasympathetic effects.
• Dose:
  • Adult:
  • Symptomatic Bradycardia: 1mg IVP every 3-5 minutes (max total dose 3mg).
  • Organophosphate Poisoning: 2-6mg IV every 15-30 minutes until vitals improve.
  • Pediatric:
  • Symptomatic Bradycardia (with increased vagal tone): 0.02mg/kg (min 0.1mg; max 0.5mg); repeat to total of 1mg.
  • Endotracheal dose (not preferred): 0.03mg/kg with 5ml NSS.
• Side Effects:
  • Dilated pupils, increased heart rate, VT, VF, headache, dry mouth.
• Contraindications:
  • AMI, myasthenia gravis, GI obstruction, closed-angle glaucoma, known sensitivity to atropine, belladonna alkaloids, or sulfites.
  • Not effective for intranodal (type II) AV block or new third-degree block with wide QRS complex; tachycardia.
• Associated Protocols:
  • 5021A & P, 8083

Calcium Chloride

• Class: Electrolyte
• Indications:
  • Hyperkalemia, hypermagnesemia, hypocalcemia with tetany, beta blocker overdose, calcium channel blocker toxicity, crush syndrome.
• Mechanism of Action:
  • Increases cardiac contractility by initiating myofibril shortening, increases myocardial contractile force and ventricular automaticity.
  • Antidote for magnesium sulfate and calcium channel blocker toxicity.
• Dose:
  • Adult: 1g or 10ml IV/IO (100mg/ml), may repeat as necessary; 0.2mg/kg IV/IO over 5-10 minutes.
  • Pediatric: 0.2ml/kg IV/IO, repeat as necessary.
• Side Effects:
  • Low HR, low BP, asystole, VF, coronary and cerebral artery spasm, extravasation causes necrosis.
• Contraindications:
  • Digitalis toxicity, hypercalcemia.
• Associated Protocols:
  • 3031A/P, 5021, 5023, 6004, 8031

Captopril

• Class: ACE inhibitor; Antihypertension
• Indications:
  • Acute pulmonary edema; congestive heart failure.
• Mechanism of Action:
  • Blocks conversion of Angiotensin I to Angiotensin II, decreasing systemic vascular resistance, preload, and afterload.
  • Reduces sodium and water retention.
• Dose:
  • 25mg SL.
• Side Effects:
  • Syncope, tachycardia, hypotension, arthralgia, rash, fever, risk of hyperkalemia with DM and renal disease.
• Contraindications:
  • Known hypersensitivity or allergy to ACE inhibitors.
• Associated Protocols:
  • 5002

Dexamethasone Sodium Phosphate (Decadron)

• Class: Corticosteroid; Adrenal glucocorticoid
• Indications:
  • Anaphylaxis, acute exacerbation of bronchial asthma, high altitude cerebral edema (HACE), spinal cord injury, croup, acute mountain sickness.
• Mechanism of Action:
  • Inhibits inflammatory and immunologic responses.
• Dose:
  • Adult:
  • Acute Mountain Sickness: 4mg IM, IV or PO every 6 hours until symptoms resolve.
  • HACE: 8mg IM, IV or oral, followed by 4mg every 6 hours.
  • Bronchospasm: 0.6mg/kg IM, IV, or orally (max 16mg).
  • Pediatric:
  • AMS/HACE: 0.15mg/kg IM, IV, or orally every 6 hours (max 4mg/dose).
  • Croup: 0.6mg/kg orally, IM, IV or IO given once (max 16mg).
  • Asthma: 0.6mg/kg IM, IV or IO every 24 hours (max dose 16mg).
  • Per Dr. Tomsho: medical command may order 0.06mg/kg with a max of 10 mg.
• Side Effects:
  • Headache, restlessness, nervousness, sodium and water retention, hyperglycemia, immunosuppression, nausea/vomiting.
• Contraindications:
  • Documented hypersensitivity, systemic fungal infection, preterm infants.
• Associated Protocols:
  • 4011

Dextrose

• Class: Nutrient
• Indications:
  • Hypoglycemia, coma of unknown origin.
• Mechanism of Action:
  • Increases blood glucose concentrations.
• Dose:
  • Adults: 10% Dextrose 25g IV/IO (250ml).
  • Pediatric:
  • 10% Dextrose 5ml/kg; 25% Dextrose 2ml/kg; 12.5% Dextrose 4ml/kg.
• Side Effects:
  • Tissue necrosis if extravasation occurs.
• Contraindications:
  • Intracranial/intraspinal hemorrhage, delirium tremens, solution not clear, seals not intact, known or suspected stroke without hypoglycemia.
• Associated Protocols:
  • 3080, 6081, 7002, 7006, 7007

Diazepam (Valium)

• Class: Benzodiazepine
• Indications:
  • Major motor seizures; status epilepticus; premedication prior to cardioversion; acute anxiety.
• Mechanism of Action:
  • Benzodiazepines bind to GABA type A receptors in the brain, potentiating the inhibitory effect of GABA, thus providing sedation, skeletal muscle relaxation, and anticonvulsant activity.
• Dose:
  • Seizures:
  • Adult: 0.2mg/kg (max 10mg IV/IO), may repeat every 5 minutes until max of 0.6mg/kg.
  • Pediatric: 0.3mg/kg IV/IO/IM (max 5mg), may repeat every 5 minutes until max of 0.6mg/kg.
  • Sedation: 5-10mg IV/IO (0.1mg/kg) titrated slowly, may repeat every 5 minutes until max of 0.3mg/kg.
  • Behavioral: (IMCRASS 2) 0.05mg/kg IM (max 5mg). (IMCRASS 3-4) Double if no midazolam available.
  • Contact Command if possible: Reduce dose for >65 years.
  • Persistent dizziness: 5mg IV/IO slowly (Adults Only).
• Side Effects:
  • Lowered respirations, lower BP, drowsiness, venous irritation.
• Contraindications:
  • Children < 6 months, acute-angle glaucoma, CNS depression, alcohol intoxication, known hypersensitivity.
• Associated Protocols:
  • 3080, 4002, 4091, 5021A, 5022A & P, 5023P, 7007, 7010, 8001, 8083

Diltiazem (Cardizem)

• Class: Antiarrhythmic
• Indications:
  • Narrow complex IRREGULAR SVT (needs command); adenosine-refractory REGULAR SVT; atrial fibrillation with rapid ventricular response; atrial flutter.
• Mechanism of Action:
  • Blocks calcium movement into heart muscle cells, prolonging conduction of electrical impulses through the AV node.
• Dose:
  • 0.25mg/kg IV/IO slowly over 2 minutes; second dose 0.35mg/kg IV/IO.
• Side Effects:
  • Dizziness, weakness, headache, dyspnea.
• Contraindications:
  • Hypotension, 2nd or 3rd degree heart block, heart failure, sick sinus rhythm, Wolff-Parkinson-White syndrome.
• Associated Protocols:
  • 5022A

Diphenhydramine (Benadryl)

• Class: Antihistamine
• Indications:
  • Anaphylaxis, allergic reaction.
• Mechanism of Action:
  • Histamine receptor blocker, reducing bronchoconstriction and vasodilation.
• Dose:
  • Adult: 50mg IV/IM/IO/PO.
  • Peds: 1mg/kg IV/IO/IM/PO (max 50mg).
• Side Effects:
  • Drowsiness, sedation, seizures.
• Contraindications:
  • Acute asthma (thickens secretions); patients with cardiac histories; known sensitivity, patients taking MAO inhibitors; newborns/nursing mothers.
• Associated Protocols:
  • 4011

Dobutamine

• Class: Adrenergic Inotropic Agent
• Indications:
  • CHF with cardiogenic shock (SBP 70-90 mmHg), post-ROSC hypotension.
• Mechanism of Action:
  • Beta-1 agonist with positive inotropic effects, increasing cardiac contractility and stroke volume; mild beta-2 agonist.
• Dose:
  • 5-20 mcg/kg/min; start at 5mcg/kg/min, increase every 10 minutes by 5mcg/kg/min until SBP >100mmHg.
• Side Effects:
  • Angina, PVCs, tachydysrhythmia.
• Contraindications:
  • Hypersensitivity, hypovolemia.
• Associated Protocols:
  • 5002

Dopamine

• Class: Inotropic, Vasopressor
• Indications:
  • Cardiogenic and septic shock; hypotension with low cardiac output.
• Mechanism of Action:
  • Stimulates alpha and beta adrenergic receptors.
  • Moderate doses stimulate B1, increasing inotropic effects and cardiac output; higher doses cause vasoconstriction (alpha dominance).
• Dose:
  • Start at 5mcg/kg/min, increase every 10 minutes by 5mcg/kg/min until SBP >100mmHg.
  • (>120mmHg in ROSC or [70+(age x 2)] in children)
  • DO NOT exceed 20mcg/kg/min unless ordered by medical command physician.
• Side Effects:
  • Headache, anxiety, dyspnea, dysrhythmias.
• Contraindications:
  • Pheochromocytoma, VF, VT, or other ventricular arrhythmias; known sensitivity (including sulfites).
  • Correct hypovolemia with fluid replacement before administering dopamine; trauma.
• Associated Protocols:
  • 3000A, 3080, 5002, 5021A & P, 6002, 7005

Droperidol

• Class: Antiemetic/Antipsychotic
• Indications:
  • Nausea and vomiting; excited delirium/psychosis; need for chemical restraint.
• Mechanism of Action:
  • Reduces motor activity, anxiety, and causes sedation; blocks dopamine receptors in chemoreceptor trigger zone (anti-emetic property); binds to postsynaptic GABA receptors in the CNS, enhancing the inhibitory effect of GABA, leading to sedation and anti-anxiety activities.
• Dose:
  • Adult: 1.25mg IV/IO/IM (nausea).
  • If >65 years or <60 kg, 0.625mg, may repeat after 15 minutes.
  • 5mg (agitated).
• Side Effects:
  • Hypotension, tachycardia, somnolence, anxiety, dysphoric mood, prolonged QT interval.
• Contraindications:
  • Hypersensitivity and prolonged QT interval.
• Associated Protocols:
  • 7010, 8003

Duoneb (Albuterol and Atrovent)

• Class: Bronchodilator / Antiasthmatic
• Indications:
  • Bronchospasm secondary to COPD; bronchial asthma.
• Mechanism of Action:
  • Combination drug:
  • Albuterol: Selective beta-2 agonist stimulating adrenergic receptors, causing bronchodilation.
  • Ipratropium: Inhibits acetylcholine action at bronchial smooth muscle receptor sites, leading to decreased cyclic GMP and bronchodilation.
• Dose:
  • 0.5mg of Ipratropium / 3mg of Albuterol nebulized over 15-20 minutes. Repeat PRN.
  • Half Dose if <14 y/o.
• Side Effects:
  • Headache, fatigue, lightheadedness, dizziness, irritability, restlessness, pulmonary edema, cough, worsening COPD symptoms, hypertension, flushing, palpitations, tachycardia, nausea/vomiting, dry mouth, epigastric pain, GI distress, tremors, blurred vision.
• Contraindications:
  • Hypersensitivity.
• Associated Protocols:
  • 4011, 4022, 4023

Enalapril

• Class: ACE inhibitor; Antihypertension
• Indications:
  • Acute pulmonary edema; congestive heart failure.
• Mechanism of Action:
  • Blocks the conversion of Angiotensin I to Angiotensin II, decreasing systemic vascular resistance, preload, and afterload. Reduces sodium and water retention.
• Dose:
  • 0.625-1.25mg IV or 25mg SL.
• Side Effects:
  • Syncope, tachycardia, hypotension, arthralgia, rash, fever, risk of hyperkalemia with DM and renal disease.
• Contraindications:
  • Known hypersensitivity or allergy to ACE inhibitors.
• Associated Protocols:
  • 5002

Epinephrine 1mg/ml (Formerly 1:1000)

• Class: Non-Selective Beta Agonist
• Indications:
  • Severe anaphylaxis; asthma (bronchospasm) needing medical command.
• Mechanism of Action:
  • Catecholamine with strong alpha adrenergic, strong beta-1, and moderate beta-2 effects.
  • Alpha stimulation causes systemic vasoconstriction, increasing peripheral vascular resistance.
  • Beta-1 stimulation increases heart rate, myocardial contractility, cardiac output, and oxygen demand.
  • Beta-2 stimulation results in bronchial smooth muscle dilation.
• Administration:
  • Medication is given IM, not IV.
• Dose:
  • Adult: 0.3mL IM every 5-15 minutes as needed.
  • Peds: 0.01mg/kg max 0.3mg IM.
  • Epi infusion may be ordered (1mg/250ml), run until hypotension resolves.
• Side Effects:
  • Tachydysrhythmias, V-Tach, V-Fib, hypertension, angina.
• Contraindications:
  • Caution in patients with known cardiovascular disease or >45 years; hypertension, cerebrovascular disease; shock from causes other than anaphylactic shock; closed-angle glaucoma; diabetes; pregnant women in active labor; known sensitivity to epinephrine or sulfites.
• Associated Protocols:
  • 4011, 4022, 4023

Epinephrine 0.1mg/ml (Formerly 1:10,000)

• Class: Vasopressor
• Indications:
  • Cardiac arrest.
• Mechanism of Action:
  • Catecholamine with strong alpha adrenergic, strong beta-1, and moderate beta-2 effects.
  • Alpha stimulation results in systemic vasoconstriction, increasing peripheral vascular resistance.
  • Beta-1 stimulation increases heart rate, myocardial contractility, cardiac output, and oxygen demand.
  • Beta-2 stimulation results in bronchial smooth muscle dilation.
• Dose:
  • 1mg IV/IO repeated every 3-5 minutes until circulation restored.
• Push Dose:
  • Prepare 1:100,000 concentration by adding 1ml of 0.1mg/ml concentration in 9ml NSS, then administer 1-2ml every 2 minutes titrated to SBP target.
• Infusion:
  • Must administer by electronic pump at 0.1-0.5 mcg/kg/min titrated to SBP target.
  • Nebulized:
  • Adult: 0.3mg (3ml) @ 6lpm.
  • Peds: 0.5mg (5ml) @6lpm.
• Side Effects:
  • Tachydysrhythmias, V-Tach, V-Fib, hypertension, angina.
• Contraindications:
  • Arrhythmias other than VF, asystole, PEA; cardiovascular disease; hypertension; cerebrovascular disease; shock from causes other than anaphylactic shock; closed-angle glaucoma; diabetes; pregnant women in active labor; known sensitivity to epinephrine or sulfites; caution in patients >45 years.
• Associated Protocols:
  • 3000A, 3031, 3032, 3033, 3080, 5021, 6002, 7005

Etomidate

• Class: Hypnotic
• Indications:
  • Sedation-assisted intubation.
• Mechanism of Action:
  • Exact action unknown, appears to have GABA-like effects.
• Dose:
  • 0.3mg/kg over 30 seconds; max 30mg.
• Side Effects:
  • Trismus (lockjaw), apnea (short duration), respiratory depression, hypoventilation, hyperventilation.
• Contraindications:
  • Known sensitivity; use in pregnancy only if patient benefits justify risk to fetus; avoid during labor and in nursing mothers.
• Associated Protocols:
  • 4002

Fentanyl

• Class: Opioid analgesic
• Indications:
  • Pain; acute coronary syndrome (given if pain unrelieved after 3 doses of NTG & SBP >100 mmHg).
• Mechanism of Action:
  • Binds to opiate receptors, producing analgesia and euphoria.
• Dose:
  • 50-100mcg IV/IO/IM/Intranasal (1mcg/kg) - may repeat ½ dose every 5 minutes until max of 3mcg/kg (300mcg).
• Side Effects:
  • Rigid chest syndrome, respiratory depression, hypotension, bradycardia, decreased level of consciousness, nausea/vomiting, laryngospasm, arrhythmias.
• Contraindications:
  • Known sensitivity, use with caution in traumatic brain injury, respiratory depression.
• Associated Protocols:
  • 3080, 4002, 4091, 5001, 6003, 6071

Furosemide (Lasix)

• Class: Non-Potassium Sparing Loop Diuretic
• Indications:
  • Congestive heart failure; pulmonary edema.
• Mechanism of Action:
  • Inhibits sodium and chloride ion absorption, as well as water in the loop of Henle and convoluted tubule of nephron.
• Dose:
  • IV furosemide dose equivalent to patient's daily PO dose (40mg-100mg) (needs medical command).
• Side Effects:
  • Hypokalemia, hypotension secondary to hypovolemia, dehydration.
• Contraindications:
  • Known sensitivity to sulfonamides or furosemide; anuria; hypovolemia; hypokalemia.
• Associated Protocols:
  • Command Call Only

Glucagon

• Class: Hormone / Pancreatics
• Indications:
  • Hypoglycemia; beta-blocker overdose unresponsive to calcium chloride; calcium channel blocker overdose unresponsive to calcium chloride.
• Mechanism of Action:
  • Converts glycogen to glucose.
• Dose:
  • Hypoglycemia: 1mg IM or Intranasal for ≥ 20kg or ≥ 5 y/o.
  • Pediatric: 0.5mg IM/IN for < 20kg or <5 y/o.
  • Allergic Reaction: 1-2mg IV q 5min (until 10mg max dose).
  • Beta-blocker or calcium channel blocker OD: 3-5mg IV/IO (0.05mg/kg); may be repeated in 10-15 minutes.
• Side Effects:
  • None noted.
• Contraindications:
  • Pheochromocytoma, insulinoma, known sensitivity.
• Associated Protocols:
  • 4011, 5021, 5023, 7002, 7007, 8031

Hydrocortisone (Solu-Cortef)

• Class: Corticosteroid; Adrenal glucocorticoid
• Indications:
  • Shock with history of adrenal insufficiency or long-term steroid dependence; anaphylaxis; asthma; COPD.
• Mechanism of Action:
  • Anti-inflammatory; immunosuppressive with salt-retaining actions.
• Dose:
  • 0-3 y/o: 25mg IV/IO/IM; 3-12 y/o: 50mg IV/IO/IM; ≥12 y/o: 100mg IV/IO/IM (IM preferred).
• Side Effects:
  • Headache, vertigo, heart failure, hypertension, fluid retention, nausea.
• Contraindications:
  • Documented hypersensitivity, systemic fungal infection, preterm infants.
• Associated Protocols:
  • 4011, 7005

Hydroxocobalamin

• Class: Antidote
• Indications:
  • Known or suspected cyanide toxicity.
• Mechanism of Action:
  • Binds cyanide, converting it to cyanocobalamin (vitamin B12), which is then excreted.
  • Cyanide disrupts metabolism dependent on metal-containing enzymes and can cause metabolic acidosis.
• Dose:
  • 70mg/kg IV/IO; max 5g; medical command may order up to 10g.
• Side Effects:
  • Hypertension, chromaturia, nausea/vomiting, headache, rash.
• Contraindications:
  • Known anaphylaxis to hydroxocobalamin or cyanocobalamin.
• Associated Protocols:
  • 8081

Ibuprofen

• Class: NSAID
• Indications:
  • Minor to moderate pain from trauma.
• Mechanism of Action:
  • Non-selectively inhibits cyclooxygenase (COX), required for prostaglandin synthesis via the arachidonic acid pathway.
  • Inhibition of COX leads to lesser prostaglandin production.
• Dose:
  • 10mg/kg (max 600mg orally).
• Side Effects:
  • GI bleeding, nausea/vomiting, diarrhea.
• Contraindications:
  • Abdominal pain, allergy to NSAIDs, NSAID intake < 6 hours ago, renal insufficiency, GI bleeding, pregnancy.
• Associated Protocols:
  • 6003, 7003

Ketamine

• Class: Anesthetic
• Indications:
  • Excited delirium; induction for intubation; pain management.
• Mechanism of Action:
  • Interacts with NMDA, opioid, monoaminergic, muscarinic receptors, and voltage-sensitive calcium ion channels.
  • Unlike other anesthetics, does not interact with GABA receptors.
• Dose:
  • Excited Delirium: single dose: 4mg/kg IM (max 400mg) OR if IV/IO in place, 2mg/kg IV/IO (max 200mg).
  • Induction for Intubation: 2mg/kg IV/IO; may repeat once if inadequate.
  • Pain Management: 0.3mg/kg in 100ml NSS over 10mins (max 30mg).
• Side Effects:
  • Blurred or double vision, dizziness, drowsiness, nausea, vomiting, dissociation, involuntary muscle movements, bradycardia, slurred speech.
• Contraindications:
  • Uncontrolled hypertension, increased ICP/IIO pressure, hypovolemia, dehydration, cardiac disease (particularly angina, CHF).
  • Not recommended for patients <15 years old.
• Associated Protocols:
  • 4002, 6003, 7003, 8002

Levalbuterol (Xopenex)

• Class: Sympathomimetic, bronchodilator, short-acting beta-2 adrenergic agonist
• Indications:
  • Treatment of acute bronchospasm in reversible obstructive airway disease (COPD/asthma). Bronchospasm prophylaxis in asthma.
• Mechanism of Action:
  • Stimulates beta-2 receptors.
• Dose:
  • Adult: 1.25mg in 3ml NS nebulized over 5-15 minutes, repeated as necessary.
  • Pediatric: same dose as adults.
• Side Effects:
  • Headache, anxiety, dizziness, restlessness, hallucinations, throat irritation, tachycardia, hypertension/hypotension, dysrhythmias, angina, nausea/vomiting, dyspepsia, tremors, hypokalemia, hyperglycemia.
• Contraindications:
  • Known hypersensitivity to drug, other sympathomimetics, or peanuts. MAOI use within 14 days, angioedema, tachydysrhythmias, severe cardiac disease. Caution with drugs that prolong QT interval.
• Associated Protocols:
  • 4022, 4023, 4011

Levophed (Norepinephrine)

• Class: Adrenergic receptor agonist
• Indications:
  • Non-hypovolemic shock/hypotension.
• Mechanism of Action:
  • Norepinephrine acts on α1, β1, and β2 receptors with the strongest α1 activity leading to vasoconstriction, with moderate β1 receptor activity contributing to cardiac stimulation.
• Dose:
  • 0.05-0.5 mcg/kg/min, increasing by 0.05 mcg/kg/min every 5 minutes to a MAP of 65 mmHg.
• Side Effects:
  • Hypertension, reflex bradycardia, mesenteric or peripheral ischemia.
• Contraindications:
  • Sulfite allergy.
• Associated Protocols:
  • 6002, 3080

Lactated Ringers

• Class: Isotonic Crystalloid
• Indications:
  • Hypovolemic shock; burns; dehydration.
• Mechanism of Action:
  • Replaces water and electrolytes; contains 600mg NaCl, 310mg Na Lactate, 30mg KCl, and chloride dehydrate.
• Dose:
  • IV/IO dose depends on patient condition and treatment situation.
• Side Effects:
  • Rare.
• Contraindications:
  • Metabolic acidosis or alkalosis, severe liver disease, or anoxic states.
• Associated Protocols:

Lidocaine 2%

• Class: Antiarrhythmic
• Indications:
  • V-Fib or pulseless V-Tach; wide complex tachycardia with pulses; control of ventricular arrhythmias (PVCs).
• Mechanism of Action:
  • Decreases automaticity; combines with fast sodium channels, inhibiting recovery after repolarization, decreasing myocardial excitability and conduction velocity.
• IO Anesthetic: 0.5mg/kg slow push up to 40mg.
• Dose:
  • For cardiac arrest VT/VF: 1.5mg/kg IV/IO; repeat 0.5-0.75mg/kg every 5-10 mins (total max dose of 3mg/kg).
  • For wide complex tachycardia: Adults 1.5mg/kg IVP; repeat 0.75mg/kg IV/IO after contacting medical command; or after ROSC start a drip of 2-4 mg/min.
  • For pediatric: 1mg/kg IV/IO (max 3mg/kg).
• Side Effects:
  • Seizures, slurred speech, altered mental status.
• Contraindications:
  • Thrombocytopenia, known sensitivity to lidocaine, sulfite, or paraben.
  • Use with caution in bradycardia, hypovolemia, cardiogenic shock, Adams-Stokes syndrome, Wolff-Parkinson-White syndrome.
• Associated Protocols:
  • 1000, 3031, 3032, 3080, 5023

Lorazepam (Ativan)

• Class: Benzodiazepine
• Indications:
  • Severe anxiety; seizures; status epilepticus; sedation.
• Mechanism of Action:
  • Benzodiazepines bind to GABA type A receptors, enhancing GABA activity, producing CNS depression as required (sedation, muscle relaxation, anticonvulsant activity).
  • Suppresses seizure activity from cortical, thalamic, and limbic areas.
• Dose:
  • Adult: 1-2mg IV/IO/IM/Intranasal (0.1mg/kg - max 2mg per dose); may repeat every 5 minutes up to max 4mg.
  • Behavioral: contact command if possible reduce dose in half for patients >65.
  • Persistent Dizziness: 1mg IV/IO slowly (Adults only).
• Side Effects:
  • Respiratory arrest, cardiac arrest, decreased LOC, hypotension.
• Contraindications:
  • Known sensitivity to lorazepam, benzodiazepines, polyethylene glycol, propylene glycol, or benzyl alcohol; COPD; sleep apnea (except when being mechanically ventilated); shock; coma; acute closed-angle glaucoma; respiratory depression.
• Associated Protocols:
  • 3080, 4002, 4091, 5021, 5022, 5023, 7007, 7010, 8001, 8083

Magnesium Sulfate

• Class: Electrolyte
• Indications:
  • Cardiac arrest; Torsades with a pulse; acute MI; seizures due to eclampsia; bronchodilator (needs command).
• Mechanism of Action:
  • Reduces striated muscle contraction.
• Dose:
  • Cardiac arrest (Torsades, hypomagnesemia): 2g IV/IO over 1-2 minutes;
  • For Torsades with a pulse: 2g IV/IO;
  • For seizures secondary to eclampsia: 1gm/min until seizure stops (max of 4gm);
  • Adult Bronchospasm: 2g IV/IO slowly over 1-2 minutes.
  • Pediatric Bronchospasm: 20-50mg/kg in 50-100ml NSS over 10-20 minutes.
• Side Effects:
  • Hypotension; asystole; cardiac arrest; respiratory depression; CNS depression; flushing; diaphoresis.
• Contraindications:
  • AV block or myocardial damage; hypotension; GI obstruction; use with caution in renal impairment.
• Associated Protocols:
  • 3031, 4022, 5023, 7007

Methylprednisolone (Solu-Medrol)

• Class: Corticosteroid
• Indications:
  • Anaphylactic reaction (requires command); asthma/COPD.
• Mechanism of Action:
  • Suppresses acute and chronic inflammation.
• Dose:
  • Adult: 40-125mg IV/IO; Pediatric: 2mg/kg.
• Side Effects:
  • CNS: Euphoria, headache, insomnia, confusion, psychosis, vertigo;
  • CV: CHF, edema, hypertension;
  • GI: Nausea, vomiting, peptic ulcer, abdominal distention;
  • Endocrine: fluid retention, hyperglycemia; hypokalemia.
• Contraindications:
  • Cushing syndrome, fungal infection, measles, varicella, known sensitivity (including sulfites).
  • Use with caution in active infections, renal disease, diabetes, penetrating spinal cord injury; hypertension, seizures, CHF; caution in GI bleeding patients.
• Associated Protocols:
  • 4011, 4022

Midazolam (Versed)

• Class: Sedative
• Indications:
  • Sedation-assisted intubation; cardiac pacing; cardioversion; seizures (including nerve agent/pesticide exposure); behavioral.
• Mechanism of Action:
  • Benzodiazepines bind to GABA type A receptors in the brain, potentiating the inhibitory effect of GABA.
  • Can produce any level of CNS depression required (sedation, muscle relaxation, anticonvulsant activity).
• Dose:
  • Post ROSC; SAI; Sedation: 1-5mg IV/IO (0.05 mg/kg, max 5mg adult, 2mg pediatric) every 5 minutes until max 0.1mg/kg.
  • Adult Seizures: 0.2mg/kg (max 10mg) IM or 0.1mg/kg (max 4mg) IV/IO;
  • N/V-Vertigo: 1mg IV/IO slowly.
  • Pediatric Seizures: 0.3mg/kg (max 10mg) IN or 0.1mg/kg (max 2mg) IV/IO every 5 minutes until max 0.2mg/kg;
  • Pediatric Sedation: 0.05mg/kg IV/IO.
  • Agitated behavior: IMCRASS 2- 0.05mg/kg IM (max 5mg);
  • IMCRASS 3-4 (with droperidol): 0.05mg/kg IM up to 5mg; (without droperidol): 0.1mg/kg IM up to 10mg.
• Side Effects:
  • Retrograde amnesia, headache, euphoria, drowsiness, excessive sedation, confusion, hypotension, and blurry vision, nystagmus, pinpoint pupils, nausea, vomiting, laryngospasm, respiratory arrest.
• Contraindications:
  • Acute-angle glaucoma, pregnant women, known sensitivity, hypotension, respiratory depression, alcohol intoxication.
• Associated Protocols:
  • 3080, 4002, 4091, 5021, 5022, 5023, 7007, 7010, 8003, 8083

Morphine Sulfate

• Class: Opioid Analgesic
• Indications:
  • Pain; myocardial infarction (MI).
• Mechanism of Action:
  • Alleviates pain through CNS action; suppresses fear and anxiety centers; depresses respiratory center; decreases preload and afterload.
• Dose:
  • For chest pain: 0.1mg/kg IV (max dose 10mg/dose) every 5 minutes (max 20mg).
  • For trauma: 2-5mg IV/IO/IM (0.1mg/kg) max 10mg/dose, repeat every 5 minutes until max of 20mg total (or peds max 0.2mg/kg).
  • For burns: Up to 0.1mg/kg IV/IO/IM (max 10mg/dose, peds max 5mg/dose), may repeat every 5 minutes until max of 0.2mg/kg.
• Side Effects:
  • Respiratory depression, low blood pressure, low heart rate, decreased level of consciousness, nausea/vomiting.
• Contraindications:
  • Respiratory depression, shock, known sensitivity; caution in hypotension, acute bronchial asthma, respiratory insufficiency, head trauma, RV infarct MI.
• Associated Protocols:
  • 5001, 6003, 6071

Naloxone (Narcan)

• Class: Narcotic Antagonist
• Indications:
  • Narcotic overdose (respiratory depression), alcohol induced coma, coma of unknown origin.
• Mechanism of Action:
  • Reverses respiratory depression due to opiate drugs; competitively inhibits narcotic receptor sites.
• Dose:
  • Adult: 0.4mg titrate to effect (max 2mg IV/IO); IM/Intranasal: max 2mg.
  • Pediatric: 0.1mg/kg IV/IO/IM/IN (max 0.4mg).
• Side Effects:
  • Withdrawal symptoms in addicted patients (tremors, increased BP); if too rapid reversal: nausea, vomiting, sweating, tachycardia.
• Contraindications:
  • Known sensitivity to naloxone, nalmefene, or naltrexone; caution in patients with supraventricular arrhythmias or other cardiac disease, head trauma, or brain tumor.
• Associated Protocols:
  • 3031, 4001, 4002, 6003, 6071, 7002

Nitroglycerin

• Class: Nitrate
• Indications:
  • CHF to decrease pulmonary venous congestion and improve cardiac output; suspected acute coronary syndrome (chest pain).
• Mechanism of Action:
  • Smooth muscle relaxant acting on vascular, bronchial, uterine, intestinal smooth muscle; reduces preload during acute pulmonary edema.
• Dose:
  • Chest Pain: 1 tablet or spray sublingually every 5 minutes (max of 3). Systolic BP must be over 100 mmHg.
  • CHF Dosage: repeat every 3-5 minutes as long as BP >100 mmHg; after initial dose give based on SBP: 3 SL tablets or spray (if SBP >180), 2 SL tablets or sprays (if SBP 140-180), 1 SL tablet or spray (if SBP 100-140).
  • IV: (Drip or Push Dose): Optional: 200 mcg slow IV push over 2 mins; repeat up to 3 doses or
  • with IV Pump: 5-200 mcg/min titrated to systolic >100.
• Side Effects:
  • Headache, hypotension, syncope, tachycardia, flushing, burning under tongue.
• Contraindications:
  • Hypotension, severe bradycardia, or tachycardia; right-sided MI; increased intracranial pressure; intracranial bleeding; patients on erectile dysfunction medications (Viagra, Cialis, Levitra); known sensitivity to nitrates.
• Associated Protocols:
  • 5001, 5002, 9001

Nitrous Oxide

• Class: Anesthetic
• Indications:
  • Musculoskeletal trauma; burns.
• Mechanism of Action:
  • Acts on the CNS as a mild intoxicant.
• Dose:
  • Blend of 50% O2 and 50% nitrous oxide.
• Side Effects:
  • Lightheadedness, confusion, drowsiness, nausea/vomiting.
• Contraindications:
  • Altered LOC, COPD patients, acute pulmonary edema, pneumothorax, decompression sickness, unable to self-administer.
• Associated Protocols:
  • 6003, 6071

Ondansetron (Zofran)

• Class: Antiemetic
• Indications:
  • Severe nausea and vomiting.
• Mechanism of Action:
  • Blocks action of serotonin.
• Dose:
  • 4mg IV/IO or ODT; for >6 months: 0.15mg/kg slow over 2-5 min (max 4mg).
• Side Effects:
  • Headaches, diarrhea, dizziness, pain, fever, extrapyramidal symptoms, seizures.
• Contraindications:
  • Known sensitivity; caution in hypokalemia, hypomagnesemia, cardiac arrhythmias; GI obstruction; prolonged QT; liver disease.
• Associated Protocols:
  • 7010

Oxytocin

• Class: Pituitary Hormone
• Indications:
  • Post-partum hemorrhage.
• Mechanism of Action:
  • Stimulates smooth musculature of the uterus, increasing muscle tone and the frequency and strength of contractions to stop bleeding.
• Dose:
  • 10-20 units/1000ml of NSS IV/IO wide open.
• Side Effects:
  • Headache, subarachnoid hemorrhage, cardiac dysrhythmias, nausea/vomiting, hyponatremia, anaphylaxis.
• Contraindications:
  • Ensure no additional fetus is present and the placenta has been delivered prior to administration.
• Associated Protocols:
  • 7087

Pralidoxime Chloride (2PAMCl)

• Class: Cholinesterase Reactivator
• Indications:
  • Organophosphate or nerve agent poisoning.
• Mechanism of Action:
  • Administered with atropine; attaches to anionic site of the enzyme, having a higher affinity for phosphorylation than the enzyme itself, enabling the enzyme activation.
• Dose:
  • Moderate: >41kg: 600mg IM; Severe: >41kg: 1800mg IM; 18-41kg: 1200mg; 7-18kg: 600mg.
• Side Effects:
  • Dizziness, headache, nausea/vomiting, tachycardia, weakness, hypertension, blurred vision.
• Contraindications:
  • Known hypersensitivity.
• Associated Protocols:
  • 8083

Procainamide

• Class: Antiarrhythmic (Class Ia)
• Indications:
  • Refractory V-Fib/Vtach; wide complex tachycardia.
• Mechanism of Action:
  • Blocks sodium entry during depolarization; raises the ventricular fibrillation threshold.
• Dose:
  • 15mg/kg slow IV/IO over 30-60 minutes.
• Side Effects:
  • Hypotension, AV block, bradycardia, QRS/QT prolongation.
• Contraindications:
  • Known hypersensitivity, hypotension (SBP
• Associated Protocols:
  • 5023 A (MC orders)

Racemic Epinephrine

• Class: Alpha and Beta agonist
• Indications:
  • Severe respiratory distress with stridor, severe or persistent at rest (retractions and tachycardia).
• Mechanism of Action:
  • Dilates bronchioles reducing wheezing and vasoconstricts reducing upper airway edema.
• Dose:
  • 0.5ml nebulized in 2ml NSS or epinephrine 1mg/1ml-5ml.
• Side Effects:
  • Tachycardia, headache, nausea, tremors, restlessness, angina.
• Contraindications:
  • MAOIs.
• Associated Protocols:
  • 4023 P

Sodium Bicarbonate

• Class: Electrolyte (Alkalinizer)
• Indications:
  • Cardiac arrest if hyperkalemia or antidepressant overdose; crush injury; hyperkalemia; tricyclic overdose; phenobarbital overdose; diphenhydramine overdose; acetylsalicylic acid overdose; cocaine overdose.
• Mechanism of Action:
  • Buffers metabolic acidosis and lactic acid buildup.
• Dose:
  • 1mEq/kg IV/IO; Pediatric: 1-2mEq/kg; crush injury: 1mEq/kg just prior to extrication, with QRS widening repeat dosage.
• Side Effects:
  • Metabolic alkalosis; hypokalemia; fluid overload.
• Contraindications:
  • Metabolic alkalosis, hypocalcemia.
• Associated Protocols:
  • 3031, 5023, 6004, 8031, 8081

Sodium Chloride (Normal Saline Solution)

• Class: Isotonic Solution
• Indications:
  • Heat exhaustion and related heat problems; diabetic disorders; freshwater drowning; head injury; hypovolemia.
• Mechanism of Action:
  • Replaces water and electrolytes.
• Dose:
  • IV/IO dose dependent upon patient condition and situation being treated.
• Side Effects:
  • Volume overload; congestive heart failure; diuresis; thirst.
• Contraindications:
  • Pulmonary congestion, pulmonary edema, known sensitivity.
• Associated Protocols:

Sodium Thiosulfate

• Class: Antidote
• Indications:
  • Cyanide toxicity.
• Mechanism of Action:
  • Donates sulfur atom required to transform cyanomethemoglobin to thiocyanate, thus detoxifying cyanide.
  • Cyanide binds to ferric iron in the cytochrome oxidase system, disrupting oxidative phosphorylation and causing shift to anaerobic metabolism, leading to metabolic acidosis.
• Dose:
  • Adult: 12.5 grams (50 ml) IV/IO over 1-2 minutes.
  • Pediatric: 1.6ml/kg IV/IO over 1-2 minutes (max dose 12.5 grams).
• Side Effects:
  • Nausea/vomiting, headache, hypotension.
• Contraindications:
  • None; precaution noted against concurrent administration with hydroxocobalamin.
• Associated Protocols:
  • 8031, 8081

Tetracaine 0.5% Ophthalmic Solution

• Class: Local anesthetic (ester group)
• Indications:
  • Corneal abrasion or injury.
• Mechanism of Action:
  • Blocks sodium ion channels required for initiating and conducting neuronal impulses, achieving corneal local anesthesia within 10-20 seconds, lasting 10-20 minutes.
• Dose:
  • Adult: 2 drops in affected eye.
• Side Effects:
  • Burning, conjunctival redness, ocular discomfort.
• Contraindications:
  • None noted.
• Associated Protocols:
  • 8031

Terbutaline

• Class: Selective Beta-2 agonist
• Indications:
  • Bronchospasm.
• Mechanism of Action:
  • Stimulates beta-2 receptors causing relaxation of bronchial smooth muscle and prompt bronchodilation.
• Dose:
  • Adult: 0.25mg IM.
• Side Effects:
  • Tachycardia, anxiety, nervousness, tremors, headache, palpitations, nausea/vomiting.
• Contraindications/Medication Interactions:
  • CHF, pregnancy, hypersensitivity; caution if taking MAOIs or TCAs.
• Associated Protocols:
  • 4022

Toradol (Ketorolac)

• Class: Nonsteroidal Anti-inflammatory Drug; Anti-inflammatory
• Indications:
  • Treat moderate to severe pain.
• Mechanism of Action:
  • Blocks effects of COX-1 and COX-2 enzymes, which are key to making prostaglandins, reducing PG production and associated effects.
• Dose:
  • 15mg IV/IO (30mg IM); preferred IV if kidney stone suspected (Peds ≥2y/o: 0.5mg/kg IV/IO/IM, max 15mg IV/IO or 30mg IM).
• Note:
  • NSAIDs contraindicated if an oral NSAID taken in the last 6 hours; or history of bleeding/suspected bleeding (external/internal trauma, GI, vascular); known kidney disease/failure or kidney transplant.
• Side Effects:
  • Headache, abdominal pain, nausea/vomiting, dizziness, drowsiness, edema, hypertension, pruritus, rash, stomatitis, purpura, sweating, peptic ulcer, GI bleed/perforation, renal/liver failure, anaphylaxis, skin reactions.
• Contraindications:
  • History of peptic ulcer disease/GI bleeds; renal insufficiency; hypovolemic patients; pregnancy (third trimester); nursing mothers; known allergy to ASA or other NSAIDs; stroke/suspected stroke; need for major surgery in the immediate future.
• Associated Protocols:
  • 6003, 7003

Tranexamic Acid

• Class: Coagulation modifier, Antifibrinolytic
• Indications:
  • Traumatic bleeding.
• Mechanism of Action:
  • Synthetic derivative of lysine inhibiting fibrinolysis by blocking lysine binding sites on plasminogen, preventing clot breakdown.
  • Additional mechanisms including decreasing inflammatory responses to trauma are under exploration.
• Dose:
  • 1g over 10 minutes (1g/100ml NSS).
• Side Effects:
  • Hypotension, nausea/vomiting, diarrhea.
• Contraindications:
  • Do not use with blood products or penicillin in the same IV/IO line.
• Associated Protocols:
  • 6094

Verapamil

• Class: Calcium Channel Blocker
• Indications:
  • PSVT refractory to adenosine; narrow complex IRREGULAR SVT (needs command); adenosine-refractory REGULAR SVT; AFib with rapid ventricular response; atrial flutter.
• Mechanism of Action:
  • Causes vascular dilation and slows conduction through the AV node; inhibits re-entry dysrhythmias such as PSVT.
  • Decreases myocardial oxygen demand due to inotropic effects.
• Dose:
  • 5mg IV over 2-3 minutes; repeat 5-10mg in 15 minutes.
• Side Effects:
  • Nausea, vomiting, dizziness, headache, bradycardia, heart block, hypotension, asystole.
• Contraindications:
  • Severe hypotension, cardiogenic shock, VTach; check WPW before treating patients in atrial flutter or fibrillation.
• Associated Protocols:
  • 5022